Dejour et al.

Journal of
Journal of Experimental Orthopaedics (2021) 8:109
https://doi.org/10.1186/s40634-021-00430-2 Experimental Orthopaedics

ORIGINAL PAPER Open Access

Updated treatment guidelines for patellar

instability: “un menu à la carte”
David H. Dejour1, Guillaume Mesnard1 and Edoardo Giovannetti de Sanctis1,2*

Introduction The patellar articular side has similar and congru-

Patellofemoral disorders could be named the worse
pathology to treat for an orthopaedic surgeon. The high
variability in terms of clinical figures, psychologic con-
sequences on sometimes very young patients with par-
ents who often feel guilty of the situation, the poor and
pretty unspecific clinical exam and the necessity of a
perfect technical imaging mixing plain radiographs and
slice imaging with a high level of knowledge to interpret
them. This makes the final diagnosis and the treatment
algorithm difficult, whereas taking all these data step by
step could lead to a more simple and secure care for the
patient.
The goal of this article is to clarify, to simplify the way
to overlook the patient in the light of experience and
objective data coming from literature.
Patellar instability: definition
Patellofemoral instability is a multifactorial disease
including a spectrum of different conditions.
Patellar dislocations occur more frequently in the sec-
ond decade of life, mainly in female adolescent patients.
The incidence of patellar instability varies between
5.8/100,000 and 29/100,000 in the 10-17 year old age
group [36].
The Patellofemoral joint stability depends on both bone
morphology and soft tissue restraints, and it has a role of
fundamental importance for proper functioning of the
knee extensor mechanism.
The groove lateral facet is higher, larger and more pro-
tuberant anteriorly than the medial one.
*Correspondence: edoardo.giovannettids@gmail.com
2
Lyon Ortho Clinic, 29 Av. des Sources, 69009 Lyon, France
Full list of author information is available at the end of the article
ent characteristics. The importance of the trochlear lat-
eral facet in resisting lateral forces is rational and widely
accepted.
Furthermore, the lateral retinaculum is stronger and
wider in relation with the medial side.
A mechanical imbalance, often associated with ana-
tomic abnormalities, with laterally overcoming the medi-
ally directed forces, may lead to dislocation.
H. Dejour and the school of Lyon [14] classified
patients having patellofemoral (PF) pathology associated
with instability in three groups: Objective Patellar Insta-
bility/ Objective Patellar Dislocation (OPI/OPD), Poten-
tial Patellar Instability/ Potential Patellar Dislocation
(PPI/PPD) and Painful patellar syndrome (PPS) using
clinical history and an objective description with statisti-
cal threshold for anatomical abnormalities (Table 1).
OPI or OPD group includes patients with two charac-
teristics: both a history of at least one documented patel-
lar dislocation, defined as a complete displacement of the
patella with respect at least one anatomical risk factor.
The cases of pure traumatic patellar dislocation are rare
and therefore excluded from this classification. These
patients, due to their normal patellofemoral anatomy,
usually have a patella which is difficult to be relocated
within the groove after the acute episode.
The dislocation has to be objectively documented;
mostly children and adolescent may confuse episodes of
patellar subluxation as true complete dislocation totally
different from the feeling of instability related to the
quadriceps inhibition.
OPI/OPD group may be further classified, based on the
number and type of the dislocation in recurrent (more
than 3 episodes), habitual (during each early knee flexion)

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Dejour et al. Journal of Experimental Orthopaedics (2021) 8:109
Table 1 Classification according to H. Dejour et al.
Groups Knee Pain Anatomic Risk Documented
factors Dislocation
OPI/OPD X X X
PPI/PPD X X
PPS X
and permanent (always dislocated throughout the whole
range of motion) patellar dislocation.
More frequently patients within this group have a com-
plete displacement with no pain reducing spontaneously,
due to the presence of anatomical abnormalities influenc-
ing the normal stability of the patella.
PPI or PPD group includes patients with at least one
anatomic instability factor complaining of knee pain but
without reporting any documented patellar dislocations.
Maltracking and subluxations (defined as partial loss of
contact) might be found in the affected or more com-
monly in the contralateral knee.
PPS group includes patients complaining of knee pain
but without having any anatomic instability factor or
reporting any documented dislocation/subluxation.
Actually, large part of this group does not belong to spec-
trum of disorders termed patellar instability.
Clinical presentation and examination
Common symptoms
Anterior knee pain, subjective feeling of unstable knee,
and locking or catching are frequent clinical symptoms
developing in patients with patellar instability. During
the clinical observation the physician should figure out
whether the patella is centered within the groove or if it is
permanently subluxated/dislocated.
Main signs and tests
These signs are fundamental, influencing significantly the
diagnosis and treatment.
The Apprehension test, the Patellar Tilt test, the quad-
rant test, the J sign and/or abnormal patellar tracking are
the clinical aspects, preferred by the authors, to evaluate
the patients.
The Apprehension test is a physical finding in which
forced lateral displacement of the patella produces anxi-
ety and resistance in patients with a history of lateral
patellar instability.
The Patellar Tilt test evaluates the amount of clinical
patellar inclination, this test is performed with the knee
in full extension.
The medial tilt test identifies the reducibility of the
patellar tilt and the tightness of the lateral retinaculum.
Page 2 of 11
The quadrant test is done in extension and flexion to
evaluate the MPFL competency.
Maltracking refers to the dynamic malalignment of
the patella within the trochlear groove occurring during
active or passive range of motion of the knee.
The J-sign is the clinical sign of the disengagement in
extension of the patella from the trochlea; it is an active
sign leaded by the quadriceps contraction, it means more
often a mechanical or functional patella alta, a short or
convex trochlea.
The abnormal patellar tracking is only visible in high-
grade trochlear dysplasia. The patella could dislocate or
reduce during active or passive ROM.
A dislocation in flexion means a shorter proximal or
distal extensor mechanism, whereas a dislocation in
extension means only a high trochlear dysplasia with a
normal length of the quadriceps.
Anatomic risk factors and radiologic evaluation
This is the key to set the treatment decision. A deep
knowledge of the different anatomic abnormalities, lead-
ing to PF instability, is necessary to choose the right
treatment for each patient.
In 1987 H. Dejour et al. [14] described the four major
anatomical factors leading to patellar dislocation: troch-
lear dysplasia (TD), patella alta (PA), excessive TT-TG
distance and patellar tilt.
In the last decade, several authors have confirmed
and highlighted the importance of those risk factors,
unless the patellar tilt angle whose relevance has slightly
decreased to become a consequence of the others.
True sagittal view, axial view at 30° of knee flexion and
anteroposterior view have to be evaluated and correctly
done by radiologist for a correct treatment. The lateral
view has to be performed superimposing the two pos-
terior femoral condyles in a monopodal weight-bearing
position with 20° of flexion.
CT and MRI show perfectly the global shape of the
trochlea and are able to quantify the axial malalign-
ment (TT-TG), the patellar tilt and some rotational
deformities.
Trochlear dysplasia
Trochlear dysplasia is the main and the first risk factor
most frequently associated with patellar instability, diag-
nosed in up to 96% of patients with OPI [14].
It refers to a pathologic alteration in the shape of the
femoral trochlea (flat or shallow groove with or without
an associated supratrochlear prominence), which always
has a genetic origin.
On the radiograph sagittal view the trochlear dysplasia
is defined by three pillars: the crossing sign, the supra-
trochlear spur and the double-contour sign. The slice
Dejour et al. Journal of Experimental Orthopaedics (2021) 8:109
imaging is helpful in defining the shape of the trochlea.
The combination of both imagings is mandatory to have a
clear definition of the trochlear dysplasia (Fig. 1).
The crossing sign, first described by H. Dejour et al.
[14], is defined as the point where the trochlear sulcus
radiographic line links the projection of the anterior
femoral condyles. It represents macroscopically the exact
position where the sulcus and anterior femoral condyle
have the same AP height, indicating that a segment of the
Fig. 1 Two Imagings are mandatory to screen the trochlear dysplasia. X-Ray shows the 3 pillars of trochlear dysplasia. Slice imaging gives the shape
of the trochlea but not the supratrochlear spur
Fig. 2 Definition of the supratrochlear spur
Page 3 of 11
trochlea has become a flat. The lower the ‘crossing sign’,
the higher the grade of trochlear dysplasia.
The supratrochlear spur is a protuberance (bump or
prominence) on the superolateral part of the trochlea
with a functional effect, during the trochlear engage-
ment, similar to the ski ramp (Fig. 2).
The double-contour sign is seen radiologically as a dou-
ble line at the anterior aspect of the condyles. It repre-
sents medial hypoplastic facet with an inferior AP height
Dejour et al. Journal of Experimental Orthopaedics
compared to the sulcus and lateral condyle; it has to end
below the crossing sign.
Axial views obtained with the knee flexed 30° might be
used to evaluate the shape of the trochlea, measure the
sulcus angle and also evaluate the patella dysplasia classi-
fied according to Wiberg.
The sulcus angle (defined by Brattström [7]) is calcu-
lated by drawing two lines, from the deepest point of the
groove, towards the most superior point of each condyle.
The mean normal sulcus angle value, evaluated on radio-
graphs, is 142° ± 0.5 [7]. In trochlear dysplasia the sulcus
angle is increased or unmeasurable.
At our institution we do not commonly use the sul-
cus angle to quantify the trochlear dysplasia. Axial
Table 2 The Dejour’s classification of trochlear dysplasia
Type Sagittal View
A (54%) CS
B (17%) CS and SS
C (9%) CS and DC
D (11%) CS, SS, DC
Cross-checking the radiographic sagittal view and the cross-sectional images is fundamental to include a patient within one of those trochlear types
CS Crossing sign, SS Supratrochlear spur, DC Double contour
Fig. 3 Classification of the 4 types of trochlear dysplasia according to Dejour et al. [12] matching X-rays and Slice imaging
(2021) 8:109 Page 4 of 11
radiographs are used only to evaluate the presence of
condylar or patellar fractures. To analyze the shape of
trochlear in the axial plane, we prefer the use of slice
imaging like CT scan or MRI.
Basically, by cross-checking the radiographic sagittal
view and the cross-sectional images, trochlear dyspla-
sia might be classified, according to Dejour et al. [12],
as shown in Table 2 (Fig. 3).
Patella alta
Patella alta is the second major risk factor which could
lead to patellar dislocation alone.
The intrinsic function of the patella is to increase the
moment arm and therefore the effective extension force
Axial images
Shallower trochlea
Flat or convex
Convex lateral facet and hypoplastic medial facet
A prominent and convex lateral facet with a vertical connection
(squared) to an hypoplastic medial facet almost absent (cliff pat-
tern).
Dejour et al. Journal of Experimental Orthopaedics (2021) 8:109
of the quadriceps muscle. The position of the patella
related to the trochlea will have a huge effect on the
patellofemoral stability but also on potential pain.
In normal knees, patellar engagement with the trochlea
occurs at around 20° of flexion and the.
PF total contact area increases from extension to flex-
ion and reaches a maximum at 90°.
Patella Alta refers to an abnormal and more proximal
position of the patella in relation to the femur.
When the patella is alta it leads to a delay of the patellar
engagement within the groove during the early phase of
flexion. An increase in the “free” range of motion, with
the patella out of the restraining bony supports, would
facilitate lateral dislocation, due to the usual prevalence
of the lateral structures with respect to the medial ones.
Patella Alta increases the quadriceps moment arm,
resulting in greater compression forces and decreases the
PF contact area between 0° and 60° of flexion; those two
anomalies lead to a higher risk of cartilage degeneration
and subsequent pain [20].
Dejour et al. [13] showed that 24% and 90% of patients
with Objective Patellar Instability (OPI) had respectively
patella Alta and patellar Tilt.
Several methods have been described to quantify
patellar height on sagittal radiographs [5, 19, 21]. Our
preferred index to evaluate this aspect, is the Caton-Des-
champs index (CDI), due to the simplicity of the meas-
urement and as it is not affected by tibial tuberosities
abnormalities [8, 9] and it is easy with that to find out the
exact amount of distalization needed.
Furthermore, an International Patellofemoral Study
Group consensus established the CDI as the preferred
method for measuring patellar height [22].
It is the ratio between the distance from the patellar
inferior pole to antero-superior tibial plateau (AT) and
the length of the patellar articular surface (AP).
A ratio > 1.2 and < 0.6 are referred to as respectively
patella alta and patella infera.
Agreement between patellar height measurements
from radiographs, MRI and CT remains unclear. Vari-
ability in knee positioning quadriceps contraction and
imaging modality may modify CDI measurement.
The MRI is performed with the patient in a supine
position with extended knees.
Caton-Deschamps index on MRI is calculated with the
sagittal slice showing the patella with the greatest length
in the plan of ACL.
Yue et al. [37] showed greater CDI values on MRI than
radiographs, with a difference varying from 0.17 to 0.18.
Paul et al. stated that the CDI has strong agreement
between radiographic and magnetic resonance imaging.
The average Caton–Deschamps index was 1.23 ± 0.18 on
Page 5 of 11
radiograph and 1.26 ± 0.18 on magnetic resonance imag-
ing, with a mean difference of − 0.03 ± 0.15.
Apart from the CDI, the Lyon protocol considers the
use of another Index, measuring the patellar height and
its functional engagement with the trochlea.
Sagittal engagement index is measured as the ratio
between the articular cartilage of the patella and the
trochlear cartilage length measured on two different MRI
slices.
Dejour et al. [11] introduces a new method to measure
the Sagittal Patellofemoral Engagement (SPE) Index with
the use of MRI. It might serve as a supplementary tool
to the existing methods of evaluating patellar height, and
may help to better identify the cases where inadequate
engagement is recorded despite the absence of patella
alta measured on x-rays (Fig. 4).
They showed that a SPE < 0.45 in a patient with patel-
lar dislocation might be considered patella alta with an
insufficient functional sagittal PF engagement.
Two distinctive sagittal cuts are selected. On a first sag-
ittal cut, showing the longest patellar articular cartilage,
patellar length (PL) line is drawn, measuring the entire
length of the patellar articular cartilage. On a second sag-
ittal cut, showing the trochlear cartilage extending more
proximally, PL and a line parallel to it (TL – Trochlear
Length) with the same starting height are drawn. The TL
line reaches the most proximal articular trochlear carti-
lage. The SPE is therefore calculated as the ratio between
TL and PL.
The previously published method [4] of patellotroch-
lear index on a single image slice, does not allow its use in
cases of dislocated patella.
It is always interesting to look at indirect signs of patella
alta on slice imaging (CT scan or MRI): the highest axial
images show the patella but not the trochlea, which is
visible only once the patella has disappeared.
Another way to evaluate patella alta is by evaluat-
ing axial CT images of the patellofemoral joint with and
without quadriceps contraction. The quadriceps muscle
contraction often creates a more pathological displace-
ment of the patella with a clinical maltracking or a J sign.
TT‑TG distance
TT-TG (tibial tuberosity-trochlear groove) distance is
the third risk factor for patellar instability but differently
from trochlear dysplasia and patella alta it is not able to
lead individually to to patellar dislocation.
The TT-TG distance represents the radiographic meas-
urement of the lateral quadriceps vector acting on the
patella.
This value is modified by both femoral/tibial rotation
and varus/valgus knee coronal alignment, altering the Q
Dejour et al. Journal of Experimental Orthopaedics (2021) 8:109
Fig. 4 Patella Alta quantification: X-ray with the Caton-Deschamps index, MRI with the Sagittal Patellar Engagement index, notice the patellar
tendon length
angle, formed by the lines of pull of the quadriceps and
patellar tendon intersecting at the center of the patella. In
order to measure this angle accurately the patella should
be centered on the trochlea.
An excessive femoral anteversion, tibial external rota-
tion, subtalar joint pronation or genu valgus and genu
recurvatum are the secondary anatomic instability fac-
tors altering the coronal, clinically evaluated, Q angle
and therefore the axial, radiologically measured, TT-TG
distance.
A greater femoral anteversion, by rotating the distal
femoral epiphyses internally, increases the lateral vec-
tor leading to both a higher risk of lateral compartment
degeneration and patellar dislocation [33].
An increased TT-TG distance might lead to patel-
lofemoral disorders.
The TT-TG distance is assessed according to Lyon
Protocol [14]. The first cranial axial image depicting a
complete cartilaginous trochlea is used to draw a line
(trochlear line), perpendicular to the posterior condylar
tangent, through the deepest point of the groove. A sec-
ond line, parallel to the trochlear line, is drawn through
the most anterior portion of the tibial tubercle. The
distance between those 2 lines representes the TT-TG
distance.
Page 6 of 11
Although it is a very controversial value due to the low
reproducibility, it is the best index produced so far to
measure the Q angle. The TT-PCL value, which has been
proposed recently [31], has not shown any superiority to
the TT-TG in differentiating patients with patellofemoral
instability [6], but remain a good alternative to quantify
the axial malalignment. However, the key point is to have
measures helping the physician in evaluating the patient
and planning the surgery preoperatively and that could
be used to assess the surgical result.
Traditionally a pathological TT-TG distance, evaluated
on CT Scan, has a cut off value of 20 mm.
Recently, several authors have used magnetic reso-
nance imaging (MRI) to calculate the TT–TG distance
proposing a cut-off value of around 13 mm [34, 35].
Patellar tilt
During the 80’s the patellar tilt used to be reported as
a PF instability risk factor but later it has proved to
be only a consequence of the other three risk factors
described above. Patellar tilt refers to the inclination
of the patella in relation to the posterior bicondylar
line. An abnormal tilt value is the result of many fac-
tors, including both trochlear/patellar morphology and
medial/lateral restraints tightness imbalance. Debated is
Dejour et al. Journal of Experimental Orthopaedics (2021) 8:109
whether the Patellar tilt is a sensitive marker for patellar
instability as it may occur without patellar subluxation/
dislocation [16].
Patellar tilt is traditionally measured on CT views and
it is described by the angle formed by a line tangent to
the posterior femoral condyles and a line passing through
the transverse axis of the patella.
In the study by Dejour et al. [14], 83% of patients with
at least one episode of patellar dislocation had a patellar
tilt value greater than 20°.
In the Lyon CT Scan protocol the tilt is measured in
extension with and without quadriceps contraction; the
difference between those two values is the expression
of the disengagement of the patella from the trochlea,
describing radiologically the clinically evaluated J-Sign.
Soft tissue status in patellar dislocation
Stabilizers of the PF joint might be divided into two
groups: static-passive and active-dynamic. Imbalance
among those would predispose to patellar malalignment
and instability. Passive stabilizers include both patel-
lofemoral and patellotibial ligaments.
The MPFL (Medial Patello-Femoral Ligament) acts as a
static restraint to lateral translation of the patella. Desio
et al. [15] reported that 60% of the force directed medi-
ally and therefore restraining the lateral dislocation is
produced by the MPFL. It is fundamental to understand
that the MPFL rupture is the consequence of the lateral
patellar dislocation and never the cause and that disloca-
tions do not occur without causing the MPFL rupture.
The MPFL reconstruction is therefore not a realign-
ment procedure but should be considered as a check-rein
for the patella.
MPTL has shown more recently to have an important
role in patellar stability and it is responsible of most of
the patellar bony avulsions [38].
The iliotibial band, have some attachments to the
patella, contributing to the lateral retinaculum.
The development of an abnormal bone morphology
during growth leading to a chronic patellar tilting and
shifting contributes to a tight and thick lateral reticulum.
We should not forget one of most important dynamic
stabilizers: the VMO (Vastus Medialis Obliquus) formed
by two parts, the vertical and the oblique ones. Usually
in chronic patellar instability, the vertical part which
has higher insertion on the patella is associated with an
hypoplastic or absent oblique part, leading to a biome-
chanically non efficient action of this muscle [17, 18].
Treatment Lyon’s algorithm
The algorithm needs to be characterized by objective,
reliable and measurable data. This is the necessary con-
dition to be successful in the highest number of patients.
Page 7 of 11
The knowledge of patient’s history and the clinical exam is
a necessary but not sufficient condition. The final decision is
made on a careful analysis of both X-rays and slices imaging.
Patients have to be divided in categories based on
their anatomic features and a “menu à la carte” should
be applied to correct each abnormality performing the
appropriate surgical procedure (Fig. 5) [26, 30].
First dislocation management
After acute first-time patellar dislocations, conservative
treatment is indicated. Coronal, sagittal and axial views are
performed to first assess the presence of patellar or condy-
lar fractures and then to explore anatomic risk factors. MRI
images are indicated in emergency only in skeletally imma-
ture patients ruling out osteochondral fractures, which
impose an immediate surgery (Fig. 6).
No immobilization is required in order to avoid knee
stiffness. A light brace and/or crutches might be used to
decrease pain during the first week.
In case of a severe and painful lipohemarthrosis,
an arthrocentesis might be considered to aspirate the
intra-articular liquid and reduce the pain caused by
the increased pressure.
The rehabilitation program aims to restore complete
range of motion, strengthen the quadriceps and stretch
the knee lateral compartment soft tissues and finally
guide the medial side healing.
Several authors have proposed surgical treatment after a
first-time patellar dislocation, consisting of acute repair or
reconstruction of the torn MPFL. Debated is whether the
surgery leads to better clinical outcomes and decreased risk
of re-dislocation than conservative management [1, 27].
Currently expert consensus suggests a conservative treat-
ment after first time dislocation.
The patient is visited at 45 days to evaluate the ana-
tomic risk factors, give a prognosis on the recurrence rate
and explain the patient what could be the future.
Objective patellar dislocation
Trochlear dysplasia
Trochlear dysplasia type A does not require a specific
surgical treatment to modify the shape of the groove.
Trochlear dysplasia types B and D fit the best with sul-
cus deepening trochleoplasty, due to the trochlear promi-
nence (supratrochlear spur) [2].
This procedure’s indications are precise, i.e. recurrent
patellar dislocations with both high-grade trochlear dyspla-
sia (B or D), and patellar maltracking. The contraindications
are: established patello-femoral osteoarthritis, open growth
plates and a painful knee with no dislocations.
Sulcus deepening trochleoplasty has three functions: it
modifies the trochlear shape with a central groove and
Dejour et al. Journal of Experimental Orthopaedics (2021) 8:109 Page 8 of 11

Fig. 5 The updated treatment algorithm for patellar instability. Each abnormality has to be evaluated and surgically corrected when indicated
(“menu à la carte”)

Fig. 6 First time patellar dislocation with Lipohemarthrosis, MPFL rupture and Bone bruise. Remember to search for osteochondral fractures!

oblique medial and lateral facets; it decreases the patel-
lofemoral joint reaction force by reducing the supra-
trochlear prominence (spur); and reduces the TT-TG
value by the groove repositioning (proximal realign-
ment), often without further need of tibial tubercle
medialization (Fig. 7).
This procedure has shown good clinical outcomes
with improved PF stability [10, 23, 26].
Still debated is the proper treatment for trochlear dys-
plasia type C. Many options have been proposed: tibial
tubercle distalization of 5 mm combined with a lateral
retinaculum release or a lateral facet elevating procedure
[3] which is the preferred option.
Patella alta
In case of a Caton-Deschamps Index and/or a low Sagit-
tal Patellofemoral Engagement (SPE) Index respectively
greater and smaller than 1.2 and 0.45, a tibial tubercle
distalization is performed. The goal is to obtain a CDI of
Dejour et al. Journal of Experimental Orthopaedics (2021) 8:109
Fig. 7 Three goals of the deepening trochleoplasty: 1) Deepen the trochlea. 2) Reduce the supratrochlear spur and make the trochlea flushes with
the femoral anterior cortex. 3) Proximal realignment with the new groove aligned with the anatomical femoral axis
1. Therefore, a patient with a CDI of 34/26 would need a
distalization of 8 mm.
This procedure enables the patella to engage the troch-
lear groove in extension.
TT‑TG and secondary anatomic factors
Tibial tubercle osteotomy with a medialization decreases
the extensor mechanism valgus force and is indicated in
case of an excessive TT-TG distance. Based on whether
the measurement is taken on CT scan or MRI, the cut-off
value would be respectively 20 mm and 13 mm.
This procedure’s goal is to change the TT-TG distance,
within a range of 10 to 15 mm and 8 to 13 mm respec-
tively if measured on CT scan or MRI.
For example, the amount of medial tubercle medializa-
tion in a patient with a CT scan measured TT-TG dis-
tance of 23 mm, would be 10 mm in order to obtain a
post-operative value of 13 mm.
The five secondary anatomic instability factors pre-
viously described, altering the axial alignment are
Page 9 of 11
considered of secondary surgical importance as no path-
ologic cut-off values with an associated surgical treat-
ment algorithm have been detected. In carefully selected
patients, proximal femoral and tibial derotation osteot-
omy might be performed in case of respectively excessive
femoral anteversion and tibial external rotation. Femoral
or tibial osteotomy might correct a severe valgus knee.
MPFL and patellar tilt
The surgical planning should include systematically a
MPFL reconstruction to improve the subjective result by
the check-rein effect. Several techniques, grafts and fixa-
tion methods have been proposed so far, without proving
one of those to be superior [28, 29].
To reduce the high rate of failure rate [32], an isolated
MPFL reconstruction should not be considered as a rea-
lignment procedure. Therefore, the perfect indication is a
low-grade trochlear dysplasia (type A), a normal or sub-
normal TT-TG and no patella alta.
Lateral release might be performed only in cases of
clinical lateral tightness (Negative medial patellar tilt
Dejour et al. Journal of Experimental Orthopaedics (2021) 8:109
test) [24, 25]. The patella tilt angle value has lost its pre-
vious role within the treatment algorithm. The cut-off
value, calculated on CT scan of 20° is not used anymore.
This procedure might be performed open (e.g. once
associated with sulcus deepening trochleoplasty) or
arthroscopically. Finally the VMO plasty is not per-
formed anymore.
Updates summary
This updated treatment algorithm reflects the experience
gained during the last decades while treating this specific
and controversial knee pathology.
It confirms that the scientific approach proposed in
1987 was successful. Originally the Lyon’s team defined
and described the instability factors and proposed sta-
tistical thresholds within a “menu à la carte” algorithm.
Years after years the knowledge became the property
of the orthopedic community around the world and
brought some confirmations, validations but also some
new factors and items within the algorithm. This is a per-
fect example of a worldwide collaboration.
The conclusion highlights the major impact of intrin-
sic instability factors. The first, in order of importance,
intrinsic factor is trochlear dysplasia which needs to be
screened by radiographs and slice imaging. The second is
patella alta which needs to have a correlation between the
bone evaluation on radiographs and the cartilage assess-
ment on MRI by looking at the sagittal patello-trochlear
engagement, which is a huge added value in surgical indi-
cation. The third intrinsic factor is the axial alignment,
quantified by the TT-TG distance, taking into account
the different thresholds of CT Scan and MRI. In patel-
lofemoral disorders always evaluate the global aspect of
the patient by looking at the secondary factors. The role
of tilt and the way of calculating it has changed slightly
within the algorithm and it is referred to as a conse-
quence of the other factors. The eventual presence of
VMO dysplasia keeps on being assessed but does not
correspond to any surgical procedure anymore.
The surgical options have changed so far and the tech-
niques became more and more reliable, e.g.the MPFL
reconstruction definitely killed the so called “Insall plasty” .
The key to treat patients with patellar dislocation is to
make the right diagnosis, which is validated by at least one
of the instability factors and then apply the algorithm, con-
sisting in correcting one by one them. This, will prevent mis-
diagnosis, overdiagnosis and limits the iatrogenic surgery.
The “menu à la carte” have helped us to successfully
and better treat patellar dislocations that once seemed
impossible. However, we could clearly state that not all
the answers have been found but we are moving closer
to the goal.
Page 10 of 11
Acknowledgements
Not applicable.
Disclosure statement
D.D.: Royalties ARTHREX
G.M. and E.G.d.S. have nothing to disclose.
Authors’ contributions
D.H.D, G.M. and E.G.d.S. wrote the paper. All authors read and approved the
final manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Clinique de la Sauvegarde, Ramsay Santé, 8, Avenue Ben Gourion,
69009 Lyon, France. 2 Lyon Ortho Clinic, 29 Av. des Sources, 69009 Lyon, France.
Received: 2 November 2021 Accepted: 12 November 2021
References
1. Askenberger M, Bengtsson Mostrom E, Ekstrom W, Arendt EA, Hellsten
A, Mikkelsen C, Janarv PM (2018) Operative repair of medial patel-
lofemoral ligament injury versus knee brace in children with an acute
first-time traumatic patellar dislocation: a randomized controlled trial.
Am J Sports Med 46(10):2328–2340. https://​doi.​org/​10.​1177/​03635​
46518​770616
2. Beaufils P, Thaunat M, Pujol N, Scheffler S, Rossi R, Carmont M (2012)
Trochleoplasty in major trochlear dysplasia: current concepts. Sports
Med Arthrosc Rehabil Ther Technol 4:7. https://​doi.​org/​10.​1186/​
1758-​2555-4-7
3. Biedert RM (2020) Lengthening osteotomy with or without elevation of
the lateral trochlear facet. In: Dejour D, Zaffagnini S, Arendt EA, Sillanpää
P, Dirisamer F (eds) Patellofemoral pain, instability, and arthritis. Springer,
Berlin, Heidelberg
4. Biedert RM, Albrecht S (2006) The patellotrochlear index: a new index
for assessing patellar height. Knee Surg Sports Traumatol Arthrosc
14(8):707–712. https://​doi.​org/​10.​1007/​s00167-​005-​0015-4
5. Blackburne JS, Peel TE (1977) A new method of measuring patellar
height. J Bone Joint Surg Br 59(2):241–242. https://​doi.​org/​10.​1302/​0301-​
620X.​59B2.​873986
6. Brady JM, Rosencrans AS, Shubin Stein BE (2018) Use of TT-PCL versus
TT-TG. Curr Rev Musculoskelet Med 11(2):261–265. https://​doi.​org/​10.​
1007/​s12178-​018-​9481-4
7. Brattstroem H (1964) Shape of the intercondylar groove normally and in
recurrent dislocation of patella: a clinical and x-ray-anatomical investiga-
tion. Acta Orthop Scand Suppl 68(SUPPL 68):61–148
8. Caton J (1989) Method of measuring the height of the patella. Acta
Orthop Belg 55(3):385–386
9. Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H (1982) Patella
infera. Apropos of 128 cases. Rev Chir Orthop Reparatrice Appar Mot
68(5):317–325
Dejour et al. Journal of Experimental Orthopaedics (2021) 8:109 Page 11 of 11

10. Dejour D, Byn P, Ntagiopoulos PG (2013) The Lyon’s sulcus-deepening 30. Schottle PB, Fucentese SF, Pfirrmann C, Bereiter H, Romero J (2005)
trochleoplasty in previous unsuccessful patellofemoral surgery. Int Trochleaplasty for patellar instability due to trochlear dysplasia: a mini-
Orthop 37(3):433–439. https://​doi.​org/​10.​1007/​s00264-​012-​1746-8 mum 2-year clinical and radiological follow-up of 19 knees. Acta Orthop
11. Dejour D, Ferrua P, Ntagiopoulos PG, Radier C, Hulet C, Remy F, Chouteau 76(5):693–698. https://​doi.​org/​10.​1080/​17453​67051​00417​81
J, Chotel F, Boisrenoult P, Sebilo A, Guilbert S, Bertin D, Ehkirch FP, Chassa- 31. Seitlinger G, Scheurecker G, Hogler R, Labey L, Innocenti B, Hofmann
ing V, French Arthroscopy S (2013) The introduction of a new MRI index S (2012) Tibial tubercle-posterior cruciate ligament distance: a new
to evaluate sagittal patellofemoral engagement. Orthop Traumatol Surg measurement to define the position of the tibial tubercle in patients with
Res 99(8 Suppl):S391–S398. https://​doi.​org/​10.​1016/j.​otsr.​2013.​10.​008 patellar dislocation. Am J Sports Med 40(5):1119–1125. https://​doi.​org/​10.​
12. Dejour DH (2013) The patellofemoral joint and its historical roots: the 1177/​03635​46512​438762
Lyon School of Knee Surgery. Knee Surg Sports Traumatol Arthrosc 32. Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C
21(7):1482–1494. https://​doi.​org/​10.​1007/​s00167-​012-​2331-9 (2012) A systematic review of complications and failures associated with
13. Dejour H, Walch G, Neyret P, Adeleine P (1990) Dysplasia of the femoral medial patellofemoral ligament reconstruction for recurrent patellar
trochlea. Rev Chir Orthop Reparatrice Appar Mot 76(1):45–54 dislocation. Am J Sports Med 40(8):1916–1923. https://​doi.​org/​10.​1177/​
14. Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors of patellar 03635​46512​442330
instability: an anatomic radiographic study. Knee Surg Sports Traumatol 33. Takai S, Sakakida K, Yamashita F, Suzu F, Izuta F (1985) Rotational
Arthrosc 2(1):19–26. https://​doi.​org/​10.​1007/​BF015​52649 alignment of the lower limb in osteoarthritis of the knee. Int Orthop
15. Desio SM, Burks RT, Bachus KN (1998) Soft tissue restraints to lateral patel- 9(3):209–215. https://​doi.​org/​10.​1007/​BF002​68173
lar translation in the human knee. Am J Sports Med 26(1):59–65. https://​ 34. Tan SHS, Lim BY, Chng KSJ, Doshi C, Wong FKL, Lim AKS, Hui JH (2020) The
doi.​org/​10.​1177/​03635​46598​02600​12701 difference between computed tomography and magnetic resonance
16. Escala JS, Mellado JM, Olona M, Gine J, Sauri A, Neyret P (2006) Objective imaging measurements of tibial tubercle-trochlear groove distance for
patellar instability: MR-based quantitative assessment of potentially patients with or without patellofemoral instability: a systematic review
associated anatomical features. Knee Surg Sports Traumatol Arthrosc and meta-analysis. J Knee Surg 33(8):768–776. https://​doi.​org/​10.​1055/s-​
14(3):264–272. https://​doi.​org/​10.​1007/​s00167-​005-​0668-z 0039-​16885​63
17. Farahmand F, Senavongse W, Amis AA (1998) Quantitative study of the 35. Vairo GL, Moya-Angeler J, Siorta MA, Anderson AH, Sherbondy PS (2019)
quadriceps muscles and trochlear groove geometry related to instability Tibial tubercle-trochlear groove distance is a reliable and accurate indica-
of the patellofemoral joint. J Orthop Res 16(1):136–143. https://​doi.​org/​ tor of patellofemoral instability. Clin Orthop Relat Res 477(6):1450–1458.
10.​1002/​jor.​11001​60123 https://​doi.​org/​10.​1097/​CORR.​00000​00000​000711
18. Goh JC, Lee PY, Bose K (1995) A cadaver study of the function of the 36. Wolfe S, Varacallo M, Thomas JD, Carroll JJ, Kahwaji CI (2021) Patellar
oblique part of vastus medialis. J Bone Joint Surg Br 77(2):225–231 instability. In: StatPearls. StatPearls Publishing, Treasure Island
19. Grelsamer RP, Meadows S (1992) The modified Insall-Salvati ratio for 37. Yue RA, Arendt EA, Tompkins MA (2017) Patellar height measurements on
assessment of patellar height. Clin Orthop Relat Res 282:170–176 radiograph and magnetic resonance imaging in patellar instability and
20. Heino Brechter J, Powers CM (2002) Patellofemoral stress during walking control patients. J Knee Surg 30(9):943–950. https://​doi.​org/​10.​1055/s-​
in persons with and without patellofemoral pain. Med Sci Sports Exerc 0037-​15992​49
34(10):1582–1593. https://​doi.​org/​10.​1097/​00005​768-​20021​0000-​00009 38. Zaffagnini S, Grassi A, Marcheggiani Muccioli GM, Luetzow WF, Vaccari V,
21. Insall J, Salvati E (1971) Patella position in the normal knee joint. Radiol- Benzi A, Marcacci M (2014) Medial patellotibial ligament (MPTL) recon-
ogy 101(1):101–104. https://​doi.​org/​10.​1148/​101.1.​101 struction for patellar instability. Knee Surg Sports Traumatol Arthrosc
22. Liu JN, Steinhaus ME, Kalbian IL, Post WR, Green DW, Strickland SM, 22(10):2491–2498. https://​doi.​org/​10.​1007/​s00167-​013-​2751-1
Shubin Stein BE (2018) Patellar instability management: a survey of the
International Patellofemoral Study Group. Am J Sports Med 46(13):3299–
3306. https://​doi.​org/​10.​1177/​03635​46517​732045 Publisher’s Note
23. Longo UG, Vincenzo C, Mannering N, Ciuffreda M, Salvatore G, Berton A, Springer Nature remains neutral with regard to jurisdictional claims in pub-
Denaro V (2018) Trochleoplasty techniques provide good clinical results lished maps and institutional affiliations.
in patients with trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc
26(9):2640–2658. https://​doi.​org/​10.​1007/​s00167-​017-​4584-9
24. Malatray M, Magnussen R, Lustig S, Servien E (2019) Lateral retinacular
release is not recommended in association to MPFL reconstruction
in recurrent patellar dislocation. Knee Surg Sports Traumatol Arthrosc
27(8):2659–2664. https://​doi.​org/​10.​1007/​s00167-​018-​5294-7
25. Migliorini F, Maffulli N, Eschweiler J, Quack V, Tingart M, Driessen A (2021)
Lateral retinacular release combined with MPFL reconstruction for
patellofemoral instability: a systematic review. Arch Orthop Trauma Surg
141(2):283–292. https://​doi.​org/​10.​1007/​s00402-​020-​03689-9
26. Ntagiopoulos PG, Byn P, Dejour D (2013) Midterm results of comprehen-
sive surgical reconstruction including sulcus-deepening trochleoplasty in
recurrent patellar dislocations with high-grade trochlear dysplasia. Am J
Sports Med 41(5):998–1004. https://​doi.​org/​10.​1177/​03635​46513​482302
27. Palmu S, Kallio PE, Donell ST, Helenius I, Nietosvaara Y (2008) Acute patel-
lar dislocation in children and adolescents: a randomized clinical trial. J
Bone Joint Surg Am 90(3):463–470. https://​doi.​org/​10.​2106/​JBJS.G.​00072
28. Peter G, Hoser C, Runer A, Abermann E, Wierer G, Fink C (2019) Medial
patellofemoral ligament (MPFL) reconstruction using quadriceps tendon
autograft provides good clinical, functional and patient-reported
outcome measurements (PROM): a 2-year prospective study. Knee Surg
Sports Traumatol Arthrosc 27(8):2426–2432. https://​doi.​org/​10.​1007/​
s00167-​018-​5226-6
29. Raoulis VA, Zibis A, Chiotelli MD, Kermanidis AT, Banios K, Schuster P,
Hantes ME (2021) Biomechanical evaluation of three patellar fixation
techniques for MPFL reconstruction: load to failure did not differ but
interference screw stabilization was stiffer than suture anchor and suture-
knot fixation. Knee Surg Sports Traumatol Arthrosc. https://​doi.​org/​10.​
1007/​s00167-​020-​06389-4